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Miscellaneous (Noncardiac, Nononcologic) Applications of Fluorine 18 Fluorodeoxyglucose Positron Emission Tomography

Section: Radiology
Effective Date: January 01, 2020
Last Reviewed: January 01, 2020

Description

Positron Emission Tomography

PET scans coupled position-emitting radionuclide tracers to other molecules, such as glucose, ammonia, or water. The radionuclide tracers simultaneously emit two high-energy photons in opposite directions that can be simultaneously detected (referred to as coincidence detection) by a PET scanner, which comprises multiple stationary detectors that encircle the region of interest.

A variety of tracers are used for PET scanning, including oxygen 15, nitrogen 13, carbon 11, and fluorine 18. The radiotracer most commonly used in oncology imaging has been fluorine 18, coupled with fluorodeoxyglucose (FDG), which has a metabolism related to glucose metabolism. While FDG has traditionally been used in cancer imaging, it potentially has many other applications.

Criteria

Positron emission tomography (PET) using 2-[fluorine-18]-fluoro-2-deoxy-D-glucose (FDG) may be considered medically necessary in:

1. The assessment of select individuals with epileptic seizures who are candidates for surgery

a. In patients with epileptic seizures, appropriate candidates are patients with complex partial seizures who have failed to respond to medical therapy and have been advised to have a resection of a suspected epileptogenic focus located in a region of the brain accessible to surgery.

2. The diagnosis of chronic osteomyelitis

The use of FDG-PET for all other miscellaneous indications is investigational, including, but not limited to:

  • Central Nervous System Diseases
  •      Autoimmune disorders with central nervous system manifestations, including:
    • Behçet syndrome
    • lupus erythematosus
  • Cerebrovascular diseases, including:
    •  arterial occlusive disease (arteriosclerosis, atherosclerosis)
    •  carotid artery disease
    • cerebral aneurysm
    • cerebrovascular malformations (arteriovenous malformation and Moya-Moya disease)
    • hemorrhage
    • infarct
    • ischemia
  • Degenerative motor neuron diseases, including:
    • amyotrophic lateral sclerosis
    • Friedreich ataxia
    • olivopontocerebellar atrophy
    • Parkinson disease
    • progressive supranuclear palsy
    • Shy-Drager syndrome
    • spinocerebellar degeneration
    • Steele-Richardson-Olszewski syndrome
    • Tourette syndrome
  • Dementias, including:
    • Alzheimer disease
    • multi-infarct dementia
    • Pick disease
    • frontotemporal dementia
    • dementia with Lewy bodies
    • presenile dementia
  • Demyelinating diseases, such as multiple sclerosis
  • Developmental, congenital, or inherited disorders, including:
    • adrenoleukodystrophy
    • Down syndrome
    • Huntington chorea
    • kinky-hair disease (Menkes disease)
    • Sturge-Weber syndrome (encephalofacial angiomatosis) and the phakomatoses
  • Miscellaneous
    • chronic fatigue syndrome
    • sick building syndrome
    • posttraumatic stress disorder
  • Nutritional or metabolic diseases and disorders, including:
    • acanthocytosis
    • hepatic encephalopathy
    • hepatolenticular degeneration
    • metachromatic leukodystrophy
    • mitochondrial disease
    • subacute necrotizing encephalomyelopathy
  • Psychiatric diseases and disorders, including:
    • affective disorders
    • depression
    • obsessive-compulsive disorder
    • psychomotor disorders
    • schizophrenia
  •  Pyogenic infections, including:
    • aspergillosis
    • encephalitis
  • Substance abuse, including the central nervous system effects of alcohol, cocaine, and heroin
  • Trauma, including brain injury and carbon monoxide poisoning
  • Viral infections, including:
    •  HIV/AIDS
    • AIDS dementia complex
    • Creutzfeldt-Jakob disease
    • progressive multifocal leukoencephalopathy
    • progressive rubella encephalopathy
    • subacute sclerosing panencephalitis
  • Mycobacterium infection
  • Migraine
  • Anorexia nervosa
  • Assessment of cerebral blood flow in newborns
  • Vegetative vs locked-in syndrome
  • Pulmonary Diseases
    • Adult respiratory distress syndrome
    • Diffuse panbronchiolitis
    • Emphysema
    • Obstructive lung disease
    • Pneumonia
  • Musculoskeletal Diseases
  • Spondylodiscitis
  • Joint replacement follow-up
  • Other
    • Giant cell arteritis
    • Vasculitis
    • Vascular prosthetic graft infection
    • Inflammatory bowel disease
    • Sarcoidosis
    • Fever of unknown origin
    • Inflammation of unknown origin.

A PET scan involves 3 separate activities: (1) manufacture of the radiopharmaceutical, which may be manufactured on site or at a regional center with delivery to the institution performing PET; (2) actual performance of the PET scan; and (3) interpretation of the results

Procedure Codes

78608 78609 78811 78812 78813 78814 78815
78816 A9552 G0235

Diagnosis Codes

G40.001 G40.009 G40.011 G40.019 G40.101 G40.109 G40.111
G40.119 G40.201 G40.209 G40.211 G40.219 G40.301 G40.309
G40.311 G40.319 G40.A01 G40.A09 G40.A11 G40.A19 G40.B01
G40.B09 G40.B11 G40.B19 G40.401 G40.409 G40.411 G40.419
G40.501 G40.509 G40.801 G40.802 G40.803 G40.804 G40.811
G40.812 G40.813 G40.814 G40.821 G40.822 G40.823 G40.824
G40.89 G40.901 G40.909 G40.911 G40.919 M86.30 M86.311
M86.312 M86.319 M86.321 M86.322 M86.329 M86.331 M86.332
M86.339 M86.341 M86.342 M86.349 M86.351 M86.352 M86.359
M86.361 M86.362 M86.369 M86.371 M86.372 M86.379 M86.38
M86.39 M86.40 M86.411 M86.412 M86.419 M86.421 M86.422
M86.429 M86.431 M86.432 M86.439 M86.441 M86.442 M86.449
M86.451 M86.452 M86.459 M86.461 M86.462 M86.469 M86.471
M86.472 M86.479 M86.48 M86.49 M86.50 M86.511 M86.512
M86.519 M86.521 M86.522 M86.529 M86.531 M86.532 M86.539
M86.541 M86.542 M86.549 M86.551 M86.552 M86.559 M86.561
M86.562 M86.569 M86.571 M86.572 M86.579 M86.58 M86.59
M86.60 M86.61 M86.611 M86.612 M86.619 M86.621 M86.622
M86.629 M86.631 M86.632 M86.639 M86.641 M86.642 M86.649
M86.651 M86.652 M86.659 M86.661 M86.662 M86.669 M86.671
M86.672 M86.679 M86.68 M86.69

Professional Statements and Societal Positions Guidelines

American Academy of Neurology

Evidence-based practice parameters from the American Academy of Neurology are summarized below.

Practice Parameters on Diagnosis of Dementia

Practice Parameter Date PET Recommendation
Diagnosis of dementia 2004: reaffirmed PET imaging not recommended for routine use in diagnostic evaluation of dementia (LOR: moderate clinical certainty)
Early detection of dementia 2003: reaffirmed Not addressed
Diagnosis of new-onset PD 2006: reaffirmed

2013; retired 2016

Evidence insufficient to support or refute FDG-PET as a means of distinguishing PD from other parkinsonian syndromes
Evaluation of depression, psychosis, and dementia in PD 2006; retired 2018 Not addressed
Mild cognitive impairment 2001; 2017; 2018 Not addressed

FDG: fluorine 18 fluorodeoxyglucose; LOR: level of recommendation; PD: Parkinson disease; PET: positron emission tomography.

American Academy of Orthopaedic Surgeons

The American Academy of Orthopaedic Surgeons (2010) published evidence-based, consensus guidelines. Fluorine 18 fluorodeoxyglucose positron emission tomography (FDG-PET) was considered:

“an option in individuals in whom diagnosis of periprosthetic joint infection has not been established and are not scheduled for reoperation. (Strength of recommendation: limited [quality of the supporting evidence is unconvincing, or well-conducted studies show little clear advantage of one approach over another])”

American College of Radiology

Evidence- and consensus-based appropriateness criteria from the American College of Radiology are summarized below.

Appropriateness Criteria for Miscellaneous Indications of FDG-PET/CT

Appropriateness Criteria Last Reviewed FDG-PET/CT Criteria
Suspected osteomyelitis, septic arthritis, or soft tissue infection (excluding spine and diabetic foot) 2017
  • Usually not appropriate for (1) suspected osteomyelitis with soft tissue or juxta-articular swelling with cellulitis and a skin lesion, injury, wound, ulcer, or blister; or (2) suspected osteomyelitis with pain and swelling or cellulitis associated with site of previous nonarthroplasty hardware.
  • Usually not appropriate for suspected osteomyelitis with soft-tissue or juxta-articular swelling with a history of surgery, though “this is promising new technology but data are limited.”
Diagnosis of dementia 2001, reaffirmed 2004 PET imaging not recommended for routine use in diagnostic evaluation of dementia (LOR: moderate clinical certainty)
Early detection of dementia 2001, reaffirmed 2003, 2015 Not addressed
Diagnosis of new onset-PD 2006: reaffirmed 2013; retired 2016 Evidence insufficient to support or refute FDG-PET as a means of distinguishing PD from other parkinsonian syndromes
Evaluation of depression, psychosis, and dementia in PD 2006 Not addressed
Dementia and movement disorders 2016 May be appropriate in individuals with possible or probable AD and to differentiate suspected FTD, LBD, CJD, or vascular dementia; usually not appropriate in individuals with suspected HD, clinical features of PD or hemochromatosis, or motoneuron disease
Imaging after total knee arthroplasty 2017 Usually not appropriate for routine follow-up of asymptomatic individual, in work-up for suspected periprosthetic infection, or for evaluation of prosthetic loosening
Seizures and epilepsy 2014 Usually appropriate for surgical planning in medically refractory epilepsy; may be appropriate for new-onset seizure unrelated to trauma in adults (age ≥18 y) and for posttraumatic (subacute or chronic), new-onset seizure; otherwise, usually not appropriate for new-onset seizure
Crohn disease 2014 Usually not appropriate
Fever without source – child 2015 May be appropriate. This procedure should not be used as the initial study. Consider if extensive clinical and imaging work-up is negative.
Suspected osteomyelitis of the foot in individuals with DM 2012; revised 2019 Usually not appropriatefor initial imaging. May be appropriate for soft-tissue swelling with or without ulcer, suspected osteomyelitis or early neuropathic arthropathy changes of the foot in individuals with DM, suspected osteomyelitis of the foot in individuals with DM with or without neuropathic arthropathy, and additional imaging following radiographs.

AD: Alzheimer disease; CJD: Creutzfeldt-Jakob disease; CT: computed tomography; DM: diabetes mellitus; FDG: fluorine 18 fluorodeoxyglucose; FTD: frontotemporal dementia; HD: Huntington disease; LBD: Lewy body disease; LOR: level of recommendation; PD: Parkinson disease; PET: positron emission tomography.

Infectious Diseases Society of America

The Infectious Diseases Society of America (IDSA; 2015) published evidence-based, consensus guidelines on the diagnosis and treatment of native vertebral osteomyelitis in adults. The guidelines stated that PET “is highly sensitive for detecting chronic osteomyelitis. A negative PET scan excludes the diagnosis of osteomyelitis, including native vertebral osteomyelitis, as the sensitivity of the test is expected to be very high in view of the high concentration of red marrow in the axial skeleton.”

The IDSA (2013) published evidence-based, consensus guidelines on the diagnosis and management of prosthetic joint infections. The guidelines concluded that PET should not be routinely used to diagnose prosthetic joint infection (strength of recommendation: B [based on moderate evidence]; quality of evidence: III [expert opinion and descriptive studies]).

The IDSA (2012) published evidence-based, consensus guidelines on the diagnosis and treatment of diabetic foot infections. The guidelines concluded that the role of FDG-PET in evaluating a diabetic foot infection has not been established.

The IDSA (2018) will be publishing guidelines on the diagnosis and management of bone and joint infections in children.

Links